Recurrent Coronary Vasospasm: A Case of Kounis Syndrome from Anaphylaxis to Contrast Dye.

Kounis syndrome is characterized by acute coronary syndrome due to coronary vasospasm or thrombosis following exposure to an allergic stimulus. The presentation can be compounded by cardiovascular collapse due to cardiogenic shock from coronary vasospasm and associated vasodilatory shock from anaphylaxis. A high index of suspicion is crucial for prompt initiation of treatment, which focuses on managing the allergic or anaphylactic process. Here we present a case of coronary vasospasm and anaphylactic shock due to contrast dye exposure during percutaneous coronary intervention of an unstable coronary lesion and its associated diagnostic and therapeutic challenges.

Outcomes of bare metal versus drug-eluting stents in allograft vasculopathy.

BACKGROUND: Because of improved outcomes with drug-eluting stents (DES), we examined angiographic and clinical outcomes of bare metal stents (BMS) vs DES for discrete lesions in chronic allograft vasculopathy. METHODS: Heart transplant patients who underwent percutaneous coronary intervention were divided into one of two groups: BMS or DES. Baseline clinical characteristics, rejection episodes and procedural details were compared. Distal arteriopathy was qualitatively compared using the Gao score. End-points included angiographic in-stent restenosis, acute coronary syndrome (ACS), ST-elevation myocardial infarction, heart failure admissions and cardiac death at 1 year. Student's t-test, chi-square test and the Mann-Whitney U-test were utilized to assess the results. Correlations were assessed using Pearson's correlation coefficient. RESULTS: Forty-two patients with 80 stents (56 DES, 24 BMS) were identified. Baseline clinical characteristics, immunosuppression regimen, cardiac risk factors, frequency of rejection and procedural details were similar. Distal arteriopathy was similar (p = 0.374), suggesting equally advanced vasculopathy. Twenty-nine patients (69%) and 46 lesions (58%) were available at 1 year for clinical and angiographic follow-up. One-year diameter stenosis (26.1 +/- 21.3% vs 31.7 +/- 38.3%; p = 0.602) and binary restenosis (22.6% vs 22.7%; p = 0.774) rates were similar for DES and BMS, respectively. There were no ST-elevation infarctions; ACS [9 (16%) vs 5 (21%) p = 0.638] and cardiac death (2 in both groups) were similar for DES and BMS, respectively. Heart failure admissions were more frequent in the DES group [18 (32%) vs 5 (21%); p = 0.016]. No clinical predictors were identified. CONCLUSIONS: In-stent stenosis, ACS and cardiac death at 1 year were similar for DES and BMS. The milieu of systemic immunosuppression in heart transplant decreases the advantages of DES in allograft vasculopathy.

Regional variation in the reconstitution of flow in the internal mammary artery graft.

We report an 81-year-old man with coronary artery disease and bypass surgery with a sequential internal mammary artery (IMA) to the diagonal and then the anterior descending, who developed regional variations in the flow through his arterial conduit. Four years after his initial surgery, he developed atresia of the proximal segment of the arterial conduit due to competitive flow. After reoperation, the patient reconstituted flow in his proximal segment, but developed atresia of the distal segment. We describe for the first time, regional variation in arterial conduit patency and discuss factors controlling patency in the sequential arterial conduit.

Utility of BNP in differentiating constrictive pericarditis from restrictive cardiomyopathy in patients with renal insufficiency.

BACKGROUND: Differentiating between constrictive pericarditis (CP) and restrictive cardiomyopathy (RCMP) is difficult because of similar clinical and hemodynamic presentation. Brain natriuretic peptide (BNP) has been reported a useful noninvasive biomarker to differentiate CP from RCMP; however, its utility in patients with renal insufficiency has not been evaluated. METHODS AND RESULTS: Consecutive patients with suspected CP or RCMP were enrolled. All but 7 patients underwent transseptal catheterization. BNP, renal function, and comorbid conditions were recorded at the time of the procedure. Renal function was estimated using the Cockcroft-Gault formula. Descriptive statistics, Student t-test, and Mann-Whitney U test were performed; P < .05 was significant. Twenty-two patients had hemodynamically or surgically proven CP or RC. In patients with CP, 9 had at least Stage II kidney disease (GFR <90 mL/min, mean 58) and 8 had normal or Stage I kidney disease (GFR >90 mL/min, mean 118). BNP was higher in patients with CP and renal insufficiency versus those with CP and normal renal function (433 versus 116 pg/mL; P = .016). BNP in patients with CP and normal renal function was lower than in patients with RC (116 versus 728 pg/mL; P = .005). CONCLUSION: BNP has reduced clinical utility in renal insufficiency to differentiate CP from RCMP.

Risks of noncardiac surgery after coronary stenting.

An increased risk of major complications for noncardiac surgery after coronary stenting has been suggested. We retrospectively reviewed all cases of coronary stents from 1999 to 2003 with subsequent surgery to assess major adverse cardiovascular events (MACEs), including myocardial infarction, stent thrombosis, major bleeding, and death. Among the 56 patients identified, 8 developed MACEs; 38% underwent surgery < or =14 days after stenting, and 62% underwent surgery 15 to 42 days after stenting. No patient developed MACEs if surgery occurred >42 days after stenting. Among patients who developed MACEs, 77% of surgeries were elective, 19% were urgent, and only 4% were emergency. Noncardiac surgery 6 weeks after coronary stenting is associated with a high risk of MACEs.